A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?

This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.

Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.

Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.

Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.

Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.

Keep your environment well ventilated. This can help reduce nausea and vomiting by eliminating odors that might trigger them.

Some additional explanations are:

Choice B is wrong because eating three large meals each day can increase nausea and vomiting by overloading the stomach. It is better to eat small, frequent meals and avoid spicy, greasy, or strong-smelling foods.

Choice C is wrong because restricting intake of high-carbohydrate foods can lead to ketosis, which can worsen nausea and vomiting. High-carbohydrate foods can also help settle the stomach and provide energy.

Choice D is wrong because brushing your teeth immediately after eating can stimulate the gag reflex and cause nausea and vomiting. It is better to rinse your mouth with water or mouthwash after eating and brush your teeth at least an hour later.

Normal ranges for nausea and vomiting in pregnancy are:

• Nausea and vomiting usually start around 6 weeks of gestation and peak around 9 weeks. They usually subside by 16 to 20 weeks, but some women may experience them throughout pregnancy.
• Nausea and vomiting are considered mild if they do not interfere with daily activities or nutrition. They are considered moderate if they cause some difficulty with daily activities or nutrition. They are considered severe if they prevent adequate intake of fluids and nutrients, cause weight loss, dehydration, electrolyte imbalance, or ketonuria.
• Nausea and vomiting that are severe or persist beyond 20 weeks of gestation may indicate a complication such as hyperemesis gravidarum, molar pregnancy, multiple gestation, or infection.